Anesthesiology 2008; 109:773–4 Copyright © 2008, the American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins, Inc. Measuring the True Cost of Trauma is the leading killer of Americans aged 1–45 yr,1 study. As with many longitudinal surveys of trauma pa- but this statistic, grim as it may be, is only the tip of a tients, there is noticeable attrition over the course of fol- very large iceberg. Because trauma preferentially afflicts low-up due to refusal on the ’ part or simple inabil- the young and the active and because it is frequently ity to find them again at 6 months or 1 yr after injury. Their debilitating without being fatal, injury is far and away the numbers are consistent with—and perhaps even a little leading cause of lost productivity in the developed better than—those of similar trials, and there was no evi- world. Orthopedic injury produces obvious and well- dent difference in any of the baseline data between those documented loss of physical capability, whereas long- patients who were followed up and those who were not. term neurologic injury is at least recognized, if not well With no control group included, the authors can only Downloaded from http://pubs.asahq.org/anesthesiology/article-pdf/109/5/773/245311/0000542-200811000-00007.pdf by guest on 25 September 2021 characterized. To this list, Dr. Leone et al.2 have now report an association, rather than a true causal relation, added the late consequences of blunt thoracic injury. between and late abnormalities in Pulmonary dysfunction in trauma patients is multifacto- pulmonary function testing. It is possible that some other rial and may be the result of direct contusion of lung tissue, variable not in evidence (e.g., history of substance abuse, lung injury by broken ribs, loss of chest wall function, fat exposure to airbag propellant) is the real driver of chronic embolus from fractured long bones, aspiration of blood or pulmonary dysfunction. It is also possible that these pa- gastric contents, and the inflammatory consequences of tients were treated during their stay in , reperfusion, and transfusion therapy.3 To these some way (e.g., ventilator settings, nutrition) that would stressors must be added the iatrogenic effects of intubation make them unique and would make the results less export- and , including both barotrauma and able. I do not believe that this is the case, however. If ventilator-acquired pneumonia. Pulmonary failure necessi- anything, the results of this study are an understatement of tating protracted mechanical ventilation is common after the real problem. The authors focused only on young severe polytrauma and is often the harbinger of multiple patients, and their reported ventilator days (3.5) and inten- organ system failure and late mortality in the intensive care sive care unit days (9) actually reflected a lower injury unit. Significant research efforts during the past decade severity (or better ventilator management) than many other have led to improved ventilator design and ventilation man- trauma centers could expect. In fact, deductive reasoning agement, with increasing recognition of the interaction would suggest that in focusing their population for scien- between therapy and disease. Mortality from pulmonary tific study, the authors mostly excluded patients and causes has decreased, especially in younger patients who groups that would be expected to have a higher incidence can be expected to heal from acute if adequately of late pulmonary complications: older patients, more se- supported.4 verely injured, more badly brain injured, or less motivated As with , however, simple sur- to participate in research trials. The fact that 70% of the vival to hospital discharge after pulmonary trauma is remaining cohort was impaired should be alarming indeed, only a partial victory. Leone et al. report that 70% of their because a more generic population would be expected to patients treated for pulmonary contusion have persistent do even worse. deficits on pulmonary function testing 6 months after A final point concerns the number of trauma patients injury, with self-reported loss of physical function and that these results might apply to, and here too, the objective decrease in exercise capacity. In an era in numbers are depressing. Improved imaging capabilities which more than 90% of seriously injured patients who have increased the rate of diagnosis of pulmonary con- reach the hospital alive survive to discharge, this number tusion in trauma patients, because contusions that might should distress us.5 Although not as visible as the loss of not have been apparent on a plain radiograph can now a limb, the permanent loss of pulmonary function may be seen on computed tomography scans (and thus in- be just as damaging to the future of a trauma . cluded in an ). Most patients with a Is it possible that this finding is in error? The authors high-energy injury (vehicular trauma, a fall from a have acknowledged the potential limitations of their height) will have some degree of pulmonary contusion, and most of these, we now know, will have long-term

This Editorial View accompanies the following article: Leone impairment of pulmonary function. It was interesting ᭜ M, Bre´geon F, Antonini F, Chaumoître K, Charvet A, Ban LH, that the authors could not find a correlation between the Jammes Y, Albanèse J, Martin C: Long-term outcome in chest anatomical lung injury defined by computed tomogra- trauma. ANESTHESIOLOGY 2008; 109:864–71. phy and the patient’s eventual outcome. To some de- gree, this reflects insufficient patient numbers, but it may also mean that physiology (lung function, inflamma- Accepted for publication August 12, 2008. The author is not supported by, nor tion) and treatment effects (ventilator management) are maintains any financial interest in, any commercial activity that may be associated with the topic of this article. more important. This suggests a number of approaches

Anesthesiology, V 109, No 5, Nov 2008 773 774 EDITORIAL VIEWS for improving long-term functional outcomes, including References improved ventilator modes, rapid weaning from positive- 1. Fingerhut LA, Warner M: Health, United States, 1996–97 and Injury Chart- pressure ventilation, increased focus on pulmonary re- book. Hyattsville, Maryland, National Center for Health Statistics, 1997 habilitation, and continued study of proinflammatory 2. Leone M, Bre´geon F, Antonini F, Chaumoître K, Charvet A, Ban LH, Jammes and antiinflammatory therapeutics. Y, Albanèse J, Martin C: Long-term outcome in chest trauma. ANESTHESIOLOGY 2008; 109:864–71 These promising avenues for study will flourish only in 3. Dutton RP, McCunn M: Anesthesia for trauma, Miller’s Anesthesia, 6th the presence of increased funding for trauma research, edition. Edited by Miller RD. Philadelphia, Elsevier Churchill Livingstone, 2005, pp 2451–95 because the most obvious therapies—exercise and phys- 4. Esteban A, Ferguson ND, Meade MO, Frutos-Vivar F, Apezteguia C, ical therapy—will not have wealthy sponsors. Leone Brochard L, Raymondos K, Nin N, Hurtado J, Tomicic V, Gonza´lez M, Elizalde J, Nightingale P, Abroug F, Pelosi P, Arabi Y, Moreno R, Jibaja M, D’Empaire et al. have illuminated a population of patients in need of G, Sandi F, Matamis D, Montan˜ez AM, Anzueto A, VENTILA Group: Evolution

our assistance. It is now our task to help them. of mechanical ventilation in response to clinical research. Am J Respir Crit Downloaded from http://pubs.asahq.org/anesthesiology/article-pdf/109/5/773/245311/0000542-200811000-00007.pdf by guest on 25 September 2021 Care Med 2008; 177:170–7 Richard P. Dutton, M.D., M.B.A., University of Maryland School of 5. Morrison CA, Wyatt MM, Carrick MM: Impact of the 80-hour work week on , Department of Anesthesiology, Program in Trauma, mortality and morbidity in trauma patients: An analysis of the National Trauma Baltimore, Maryland. [email protected] Data Bank [published on-line ahead of print July 9, 2008]. J Surg Res

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